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Home My Public Portal About5026 FIESTA AVE_Plumbing__ 76A667 CE817 12/59 APPL.ICATIO FOR PLUMBING PERMIT COUNTY OF LOS ANGELES DEPARTMENT OF COUNTY ENGINEER BUILDINGP�FETY RIVISION BUILDING � JOHN A L MBI OUNTY NGINEER ADDRESS SQA eS! b WILLIAM A JENSEN SUP T OF BUILDING _ LOCALITY G FOR APPLICANT TO FILL. IN NEARSCROSS ST DS NUMBER FIXTURE OR ITEM OWNER 2 WATER CLOSET MAIL ADDRESS BATH TUB CITY TEL NO SHOWER LAVATORY CONTRACTOR / SINS ADDRESS S O 0/!-, DISHWASHER CITY @ ill-C>L/ TEL NO CONTRACTOR S STATE LAUNDRY TUB REGISTRATION NO 411 6 COUNTY ❑ CLOTHES y TEEH�WASHER DICOT� GROUP ZONE I P CESSED BY GAS SYSTEM INDUSTRIAL WASTE APPROVAL INSPECTION RECORD P. O v o H !J a $1 00 PER ITEM /1 OR FIXTURE $ ` l Q� APPROVALS PATE INSPECTOR S SIGNATURE ��PERMIT $ 2 OO UNDER S B WORK /� Q TOTAL FEES 0/D ROUGH PLUMBING GAS PIPING 1 HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY GAS VENT WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING PLUMBING HOT WATER HEATER I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR PLUMBING FIXTURES LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF GAS TEST / CALIFORNIA OR THAT I AM THE LEGAL OWNER OF THE ABOVE DESCRIBED RESIDENTIAL P PE UTILITY CO NOTIFIED SIGNATURE OF PERMIT TE FINAL ®v VALIDATION ROBERT A WOOD cK m 0 "SH SUPERVISING MECHANICAL ENG R LACG 6 z 5 v `Li 3 5 D () o n WORKERS COMPENSATION DECLARATION l APPLICATION FOR PLUMBING PERMIT �- I hereby affirm that I have a certificate of consent to self 76A667A L, insure or a certificate of Workers Compensation Insurance p CE 617(REV 10/81) � or a certified copy thereof (Sec 3800 Lab C ) COUNTY OF LOS ANGELES 4 BUILDING AND,SAFETY Policy No h(P85LO-52Ci-0--ompany EN&MbOt I a d 4 Certified copy is hereby furnished BUILDING • c FOR APPLICANT TO FILL IN(PRINT OR TYPE) CZ Certified copy is filed with thercounty building inspec ADDRESS tion department NUMBER FIXTURE OR ITEM @ FEE G LOCALITY �� r Date 1 D r9 -Applicant Gf Ed"M P 1.6C � WATER CLOSET PP NEAREST ti CERTIFICATE OF EXEMPTION FROM WORKERS BATH TUB CROSS ST COMPENSATION INSURANCE OWNER tL (This section need not be completed if the work involved by SHOWER the permit is for one hundred dollars ($100)or less ) LAVATORY MAIL ADDRESS I certify that in the performance of the work for which this permit is issued I shall not employ any person in any manner SINK CITY TEL NO so as to become subject to the Workers Compensation Laws DISHWASHER CONTRACTORCj -E.•M _PJiaMb Date_ Applicant p CLOTHES WASHER V NOTICE TO APPLICANT If after making this Certificate of ADDRESS • Exemption you should become subject to the Workers SWIMMING POOL RECEPTOR CIT , TEL NO Compensation provisions of the Labor Code you must forth LAWN SPRINKLER SYSTEM � 4 with comply with such provisions or this permit shall be STATE LIC deemed revoked WATER HEATER LICENSE NO k SZ CLASS G-'3 LICENSED CONTRACTORS DECLARATION DISTRICT NO PROCESSED BY I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS (commencing with Section 7000) of Division 3 of the Business OUTLETS OVER y' and Professions Code and my license is in full force and effect r 5 PER SYSTEM a DATE FINAL � VALIDATION O License Number 111, 1'NO$ Lic Class C_ td FINA O Contractor S's'�+11f1 Aa& Date IV..6 BY U ❑ I am exempt under,Sec B&P C for this reason y � �� 1�7�9 9 A � Plan check fee ► # o a o,o e 5 Date Signature � T PLUMBING PERMIT ISSUING FEE$ V 0 0 1 6 5 0' Y TOTAL FEE o o a 1 (a 5 0'U ° Plan check applicant SINGLE FAMILY y Q 4,Q 4 "18 5 HOME OWNER BUILDER DECLARATION Name I hereby affirm that I am exempt from the Contractor s License Address ^ ' Law for the following reason (Section 7031 5 Business and Lyt Professions Code) C,t r Tel No 5� ❑ 1 as owner of the property will do the work and the structure is not intended or offered for sale (Section , 7044 Business and Professions Code) CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for r the performance of the work for which this permit-is issued (Sec 3097 Civ C ) m Lender s Name t Lenders Address r J 1 I certify that I have read this application and state that the * 4 above information is correct I agree to comply with all County ordinances and State jaws regulating Plumbing and hereby authorize representatives of this County to enter upon the t above mentioned property for inspection purpos s �SEE REVERSE FOR EXPLANATORY LANGUAGE Aa S_i1 �S gnature of Permittee ate v